<?php
$timeAttrib = array('' => 'Select Time...', '9:00 AM' => '9:00 AM', '1:30 PM' => '1:30 PM' );
?>

<div class="large-1 columns">&nbsp;</div>
<div class="large-10 columns enrollment-menu content-views">

<?echo form_open('inquiry/applicant_data','id="check-form-submit" class="custom" data-abide autocomplete="off"');?>

	<div class="large-12 columns"><h5 class="lead">New Student Assessment & Application Form</h5></div>
	
	<hr class="clearfix">
	
		<div>
			
			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix"><?php echo $feedata->fee_desc; ?></span>
					<input type="hidden" name="desc" class="description" value="<?php echo $feedata->fee_desc; ?>" >
				</div>
				<div class="small-8 large-8 columns">
					<div class="row collapse">
							<div class="small-3 large-2 columns">
								<span class="prefix" style="z-index:1;">&#8369;</span>
							</div>
							<div class="small-9 large-10 columns">
								<input type="text" value="<?php echo number_format($feedata->fee_rate,2,'.',','); ?>" disabled="disabled" />
								<input type="hidden" name="price" class="unitprice" value="<?php echo $feedata->fee_rate; ?>" >
							</div>
					</div>
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix">First Name</span>
				</div>
				<div class="small-8 large-8 columns">
					<?='<span>'.form_error('child_fname').'</span>';?>
					<input type="text" name="child_fname" value="<?=set_value('child_fname');?>">
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix">Middle Name</span>
				</div>
				<div class="small-8 large-8 columns">
					<?='<span>'.form_error('child_mname').'</span>';?>
					<input type="text" name="child_mname" value="<?=set_value('child_mname');?>">
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix">Last Name</span>
				</div>
				<div class="small-8 large-8 columns">
					<?='<span>'.form_error('child_lname').'</span>';?>
					<input type="text" name="child_lname" value="<?=set_value('child_lname');?>">
				</div>
			</div>

			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix">Name Ext (e.g jr,II,III)</span>
				</div>
				<div class="small-8 large-8 columns">
					<input type="text" name="child_name_ext" value="<?=set_value('child_name_ext');?>">
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix">Date of Birth</span>
				</div>
				<div class="small-8 large-8 columns">
					<?='<span>'.form_error('child_bdate').'</span>';?>
					<input type="text" name="child_bdate" class="birthdate" value="<?=set_value('child_bdate');?>">
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix">Applying for Grade Level</span>
				</div>
				<div class="small-8 large-8 columns">
					<?='<span>'.form_error('level_id').'</span>';?>
					<?php echo form_dropdown('level_id', $levels, set_value('level_id'));?>
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix">School Year</span>
				</div>
				<div class="small-8 large-8 columns">
					<?='<span>'.form_error('school_year').'<span/>';?>
					<?php echo form_dropdown('school_year', $sy, set_value('school_year'));?>
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix">Cellphone Number</span>
				</div>
				<div class="small-8 large-8 columns">
					<?='<span>'.form_error('mobile_phone').'<span/>';?>
					<input type="text" name="mobile_phone" value="<?=set_value('mobile_phone');?>">
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-4 large-4 columns">
					<span class="prefix">Schedule of Testing</span>
				</div>
				<div class="small-3 large-3 columns">
					<!--<?='<span>'.form_error('schedule_for_testing').'<span/>';?>-->
					<!--<input type="text" name="schedule_for_testing" value="<?=set_value('schedule_for_testing');?>">-->
					<?='<span>'.form_error('child_exam').'</span>';?>
					<input type="text" name="child_exam" class="examdate" value="<?=set_value('child_exam');?>">
				</div>
				<div class="small-5 large-5 columns">
					<div class="row collapse">
							<div class="small-3 large-2 columns">
								<span class="prefix" style="z-index:1;">@</span>
							</div>
							<div class="small-9 large-10 columns">
								<?='<span>'.form_error('time_id').'</span>';?>
								<?php echo form_dropdown('time_id', $timeAttrib, set_value('time_id'));?>
							</div>
					</div>
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-3 large-3 columns">
					How did you hear of us:
				</div>
				<div class="small-9 large-9 columns" style="margin:2px 0px; padding:2px 0px;">
					<span class="left"><?=form_checkbox('billboard', 'yes', FALSE);?></span><span class="left">&nbsp;&nbsp;Billboard&nbsp;&nbsp;</span><span class="left"><?=form_checkbox('signs_brochures', 'yes', FALSE);?></span><span class="left">&nbsp;&nbsp;Signs/Brochures&nbsp;&nbsp;</span><span class="left"><?=form_checkbox('driving_by', 'yes', FALSE);?></span><span class="left">&nbsp;&nbsp;Driving By&nbsp;&nbsp;</span>
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-3 large-3 columns">
					&nbsp;
				</div>
				<div class="small-9 large-9 columns" style="margin:2px 0px; padding:2px 0px;">
					<span class="left"><?=form_checkbox('friends_relatives', 'yes', FALSE);?></span><span class="left">&nbsp;&nbsp;Friends/Relatives&nbsp;&nbsp;</span><span class="left"><?=form_checkbox('website', 'yes', FALSE);?></span><span class="left">&nbsp;&nbsp;Website&nbsp;&nbsp;</span><span class="left"><?=form_checkbox('bluebook', 'yes', FALSE);?></span><span class="left">&nbsp;&nbsp;Bluebook&nbsp;&nbsp;</span>
				</div>
			</div>
			
			<div class="row collapse">
				<div class="small-3 large-3 columns">
					&nbsp;
				</div>
				<div class="small-9 large-9 columns" style="margin:2px 0px; padding:2px 0px;">
					<span class="left"><?=form_checkbox('facebook', 'yes', FALSE);?></span><span class="left">&nbsp;&nbsp;Facebook&nbsp;&nbsp;</span><span class="left"><?=form_checkbox('malls', 'yes', FALSE);?></span><span class="left">&nbsp;&nbsp;Malls&nbsp;&nbsp;</span><span class="left"><?=form_checkbox('others', 'yes', FALSE);?></span><span class="left">&nbsp;&nbsp;Others&nbsp;&nbsp;</span><span class="left"><input type="text" name="for_others" autocomplete="off" ></span>
				</div>
			</div>
		
			
			
		</div>

	<hr class="clearfix">
	
	<div>
		<input type="hidden" name="brombrom" value="<?=$token;?>">
		<input type="hidden" name="inquire" value="true">
		<input type="submit" name="inquire" value="Submit" class="btn btn-primary">
	</div>

<?php echo form_close(); ?>

</div>
<div class="large-1 columns">&nbsp;</div>
</div>